NJCAA
MEDICAL EVALUATION FORM
PART 1
To be completed by student and submitted to the examining physician before (s)he examines the student.
Student ______________________________________ Parent(s) ___________________________________
Last
First
Middle
Date of Birth __________ Address ____________________________________________________________
Home Phone_____________________________
Cell _______________________________________
PERSONAL HEALTH OF STUDENT
1.
2.
3.
4.
5.
6.
7.
8.
Circle correct reply
Has had injuries or accidents requiring medical attention
Has had a surgical operation
Has been in a hospital
Has had sickness lasting longer than one week
Takes medicine now or regularly
Has a condition now under a physician’s care
Any defect of hearing or eyesight? Wear glasses, contact lens?
Any reason this student should not take part in any sport?
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
If “YES” to any question, explain here with names and dates: ______________________________________
________________________________________________________________________________________
________________________________________________________________________________________
9.
10.
11.
12.
Has had complete poliomyelitis immunization by injections (Salk) or vaccine by
mouth (Sabin)
Has had tetanus toxoid and booster inoculation within past 3 years
Has seen a dentist within the past 6 months
To his/her knowledge, the paired organs that follow are present and healthy
YES
YES
YES
NO
NO
NO
Eyes
Ears (hearing)
Lungs
Kidneys
Testicles or ovaries
Arms/legs
Fingers/toes
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
If “NO” to any questions, explain here with names and dates: ______________________________________
________________________________________________________________________________________
If a tetanus booster is indicated, I give my permission for such an inoculation to be administered by the
examining physician, _________________________________________.
13.
14.
15.
16.
Has had immunization for rubella and measles
Have any of the following: asthma, anemia, heart trouble, diabetes, kidney
problems, epilepsy or convulsions? List: ________________________________
Have any allergies or allergic to any medications? List: _____________________
Any head injuries or concussions? Date: ______________
(over)
YES
YES
NO
NO
YES
YES
NO
NO
Part 2
(To be completed by physician)
Name of student ________________________________________________________
Last
First
Middle
Age _______ Sex _______
Significant past illness or injury
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Physician’s Examination: (Check abnormal findings and explain below)
______
Height _______
Weight _______ Blood Pressure _______ Pulse Rate _______
______
Eyes
______
Ears _______________________ Hearing
______
Nose (deformities) ____________________________________________________
______
Oropharnyx ______________________________
______
Teeth (caps, dentures, braces) ______________
______
Respiratory ______________________________
Protein _______________
______
Breasts _________________________________
Sugar _______________
______
Cardiovascular ___________________________
Other
______
Abdomen (hernia, spleen, liver) ______________ Tuberculin Test______________
______
Genitalia and anus _____________ (If ordered by physician)
______
Neuromuscular ________________ Chest X-Ray (Result/Date) _____________
______
Spine (cervical, thoracic, lumbar)________________________________________
______
Extremities (special attention knees, ankles)_______________________________
Visual Acuity
R _______ L _______
R _______ L _______
Laboratory
Urinalysis
_______________
Physician’s explanation of abnormal findings:__________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Physician’s signature________________________________________________ Phone number ________________
Physician’s name typed______________________________________________
Date of examination________________________________________
AGREEMENT TO PARTICIPATE
(Intercollegiate Athletics)
I am aware that playing or practicing in any sport can be a dangerous activity involving MANY RISKS
OF INJURY. I understand that the dangers and risks of playing or practicing in the above named sport
includes, but is not limited to, death, serious neck and spinal injuries which may result in complete or partial
paralysis or brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other
aspects of the muscular-skeletal system and serious injury or impairment to other aspects of my body, general
health and well being.
Because of the dangers of participating in sports, I recognize the importance of following the coach’s
instructions regarding playing techniques, training, rules of the sport, other team rules, and to obey such
instructions.
In consideration of St. Louis Community College permitting me to practice, play or try out for St. Louis
Community College ______________________ team, and to engage in all activities related to the team,
including practicing, playing, and travel, I hereby voluntarily assume all risks associated with participation and
agree to exonerate and save harmless, St. Louis Community College, the physicians and other practitioners of
the healing arts treating me, from any and all liability, claims, causes of action or demands of any kind and
nature whatsoever which may arise by or in connection with my participation in any activities related to the St.
Louis Community College ______________________ team.
The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor,
administrator, assignees, and all members of my family.
To hereby agree to submit any disputes that may arise between myself and St. Louis Community
College, its agents, servants and employees, the athletic staff of St. Louis community college, the physicians
and other practitioners of the healing arts treating me, and all their agents, servants and employees, in
connection with my activities at St. Louis Community College, to binding arbitration before three arbitrators, in
accordance with the Rules of the American Arbitration Association.
I, ____________________________, hereby authorize and request St. Louis Community College at
Florissant Valley, and their duly authorized agents, servants or employees (including coaches, athletic trainers,
and physicians), to furnish to all professional teams, their scouts, representative agents, athletic trainers,
physicians, servants or employees, or to the Sports Information Director and media outlets, any and all
information concerning or having bearing upon my participation in athletics at St. Louis Community College at
Florissant Valley. Said authorization shall include, but is not limited to, any and all information within their
knowledge, or contained in any records under their supervision or control concerning my physical condition,
illnesses, injuries, and any treatment, hospitalization, examinations, or other tests rendered to me, and allow
them to furnish such persons or organizations originals or copies of all written reports, hospital records, tests,
x-rays, and too make such reports to such persons or organizations concerning myself as they may request.
(over)
Should I sustain injury while participating in any activity associated with St. Louis Community College
sports including tryouts, auditions, practices, games, travel, use of Fitness Center and eight lifting facility, I
hereby consent to first aid, emergency care, admission and hospitalization to an accredited hospital,
transportation costs to the hospital if appropriate, and necessary for executing such care.
I also grant permission to the St. Louis Community College team physician and/or their consulting
physicians to render any treatment or surgical care they deem reasonably.
In addition, I also authorize the athletic trainers at St. Louis Community College who are under the
direction and guidance of the St. Louis Community College team physicians to render any preventive first aid,
rehabilitation, emergency treatment that they deem reasonable and necessary to the health and well being of
an athlete.
I specifically acknowledge that ____________________ involves activity with greater risk of injury than
other sports.
USE OF TOBACCO, ALCOHOL, CONTROLLED SUBSTANCES
I am also aware that the use of tobacco, alcohol, controlled substances while under the jurisdiction of
the St. Louis Community College athletic program is in violation of the Participation Code of the NJCAA and
the College, and can result in disciplinary action.
RESPONSIBILITY FOR PROPERTY AND EQUIPMENT
Further, I understand that I am responsible for the expense incurred should I be involved in causing
damage to property or equipment while under the jurisdiction of the St. Louis Community College athletic
program, as well as for the care and return of uniforms, equipment issued to me as a participant.
PHOTO RELEASE
This is a legally-binding Release made by me, ______________________________________, to the
St. Louis Community College.
The undersigned further agrees to indemnify and hold harmless St. Louis Community College, its
governing Board and its agents, servants, officers, directors, and employees from each and every claim,
demand, loss, damage, or expense for any and all liability or damages resulting from the use of said
photograph(s), audio and/or audiovisual recordings that may in any way relate to his/her representation that
he/she is the person whose name, voice, and/or image is reflected therein.
___________________________
_______________________________________________________
Date
Signature
___________________________
______________________________________________________
Home Telephone Number
___________________________
Cell Phone number
Student I D Number
______________________________________________________
Parent or Guardian (if under 18)
PARENT INFORMATION FORM
PARENT/GUARDIAN TO COMPLETE AND RETURN TO: Team Athletic Trainer
FAILURE TO COMPLETE ALL BLANKS WILL RESULT IN CLAIMS PROCESSING DELAYS. NOTE:
Complete all blanks. If information is not applicable, indicate the reason it is not (e.g. deceased,
divorced, unknown).
Name of Athlete: _________________________________________________
Social Security #: __________________________
Sport:
_______________________
Date of Birth: __________________
College Address: _________________________________________________
Phone: _______________________
Home Address: ___________________________________________________
Phone: _______________________
City: ___________________________________
Zip: _____________
State:
_____________
Father/Guardian: _________________________________
Mother/Guardian: ________________________________
Address:
Address: ______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Employer: ______________________________________
Work Phone ______________________________________
Work Phone____________________________________
Cell Phone ______________________________________
Cell Phone_____________________________________
Home Phone______________________________________
Home Phone____________________________________
Medical Insurance
Company or Plan: _________________________________
Medical Insurance
Company or Plan: _______________________________
Address:
______________________________________
Address: ______________________________________
______________________________________
______________________________________
Policy #:
______________________________________
Policy #: ______________________________________
Phone #:
______________________________________
Phone #: ______________________________________
Employer:
Is the company or plan listed above considered a Health Maintenance Organization (HMO) or a Preferred
Provider Organization (PPO)?
YES _______ NO _______
Does your insurance or plan require a second opinion before surgery?
YES _______
NO ________
I hereby authorize St. Louis Community College and First Agency of Kalamazoo, Michigan to inspect or secure
supplies of case history records, laboratory reports, diagnoses, x-rays, and any other data covering this and/or previous
confinements and/or disabilities. A photostatic copy of this authorization shall be deemed as effective and valid as the
original.
I authorize that the college/university or its insurance agent pay the medical vendors direct for any bills incurred
from accidents that are covered under the coverage purchased by the college/university.
Parent/Guardian Signature: ___________________________________________________
(over)
Date _____________
GENERAL STATEMENT
REGARDING THE COLLEGE’S
INSURANCE COVERAGE
The athletic accident insurance at St. Louis Community College provides
EXCESS COVERAGE for your son/daughter for accidents while participating in the play
or official team practice of intercollegiate sports, including sponsored and authorized
team travel.
There is a five hundred dollar ($500) deductible to be paid before the college’s
insurance coverage may take effect. This $500 deductible must be met by either the
athlete’s out-of-pocket expense (no insurance coverage) or by the athlete’s insurance
company. If an athlete’s insurance coverage is exhausted due to medical expenses, the
college’s insurance coverage may take effect providing that the $500 deductible has
been paid.
It is important that injuries be reported to the athletic trainer so that proper
documentation and paperwork be completed in the event a claim needs to be
processed.